40. In the absence of a coordination of benefits clause, all of the following circumstances might result in recovery of more than 100% of actual health care expenses EXCEPT.
Answer: D
D: a worker's group medical plan includes a carryover deductible provision.
In the absence of a coordination of benefits clause, a worker's group medical plan that includes a carryover deductible provision would not lead to recovery of more than 100% of actual health care expenses. This provision allows for the application of deductibles from one year to the next, thereby not increasing the total recovery amount beyond actual expenses.
A) a person working for two employers has insurance through both.
This scenario can lead to recovery of more than 100% of actual health care expenses because the individual can claim benefits from both insurance policies simultaneously, potentially exceeding the total cost of care received.
B) spouses are both employed and eligible for group medical benefits.
Similar to option A, if both spouses have group medical benefits, they can coordinate their claims to cover expenses from each policy, which may result in recovery exceeding the actual expenses incurred.
C) an executive has additional coverage through an association policy.
Having additional coverage through an association policy allows the executive to file claims with both their primary insurance and the association policy, which can potentially lead to over-recovery of health care expenses.
D) a worker's group medical plan includes a carryover deductible provision.
As stated, this provision does not facilitate recovery beyond actual expenses. It merely allows deductibles to roll over, ensuring that the total reimbursement does not exceed what was actually spent on health care.
Conclusion
The correct answer is option D, as the carryover deductible provision does not contribute to exceeding 100% recovery of expenses, in contrast to the other scenarios which allow for multiple claims and potential over-recovery. Options A, B, and C illustrate situations where overlapping insurance can result in higher total reimbursements than the actual costs incurred.